The measure may be a first nationally though other states have, in recent years, passed laws requiring applicants for food stamps, cash assistance and Medicaid to undergo and pay for drug testing. The rationale: Taxpayer money shouldn't support someone's drug habit.

Ray voices the same sentiment, saying, "I'm not trying to be mean to smokers. But people who are voluntarily putting their health at risk ought to pay more toward their health care."

Equally important, says Ray, is the imperative to snuff out tobacco use.

"This will give [enrollees] another reason to quit," says Ray, who has pushed several anti-smoking policies over the years, including the most recent tobacco tax hike, which he says drove a decline in Utah cigarette sales.

"We sold 10 million fewer packs of cigarettes in 2010, and calls to the quit line increased," he says.

Insurance penalties are in vogue in the private sector, with a growing number of employers tacking monthly surcharges onto the health insurance premiums of employees who use tobacco. Utah's largest hospital chain, Intermountain Healthcare, embraced such a get-tough policy last year.

Utah's 230,000 Medicaid recipients don't pay premiums. But a third  excluding pregnant women and children  are on the hook for co-payments in the range of $3 or $5 when they visit their doctor or fill a prescription.

Charging extra, anywhere from $2 to $30 more, could prove a powerful tool for avoiding the costs of treating preventable health woes like cancer, stroke and heart disease, says Ray.

Cigarette smoking is estimated to cost this country $193 billion in lost productivity and health care spending, according to the Centers for Disease Control and Prevention.

And while Utah has notoriously low smoking rates, the habit is most prevalent among low-income households. Utahns of lower socioeconomic status  adults with less than a high school education  are nearly 10 times more likely to report cigarette use than those with a college degree, according to the state Department of Health.

Ray hasn't yet worked through details, such as how the state would monitor and enforce the co-payment; whether enrollees would have to submit to urine or blood tests or self-disclose their smoking habit.

Without seeing the bill, which is still under draft, low-income advocates don't have much to say about it. But the approach is not favored by the American Lung Association.

"We support carrots, not sticks; policies that encourage people to stop smoking," said Jennifer Singleterry, the Washington DC-based group's cessation-policy manager.

In Utah, Medicaid pays for prescription smoking deterrents such as bupropion. Pregnant women also are eligible for counseling and aids such as nicotine patches, gum and nasal sprays. In 2011, 26 percent of those who took advantage of these tools were able to quit tobacco.

Evidence shows these approaches work, said Singleterry, who fears higher co-pays "will only make it harder for people to get the help they need."

It's a concern likely shared by federal officials, admits Ray. The U.S. government funds about 75 percent of Utah's $1.8 billion Medicaid program and must approve changes to benefits and eligibility.

"I'm sure they'll have problems with it," says Ray, who may seek a waiver from existing rules. No matter, he says. "We're doing some ground breaking here. This goes back to whether taxpayers should cover the cost of smoking."

kstewart@sltrib.com

Twitter: @kirstendstewart 

What's next

A bill that would require Utah smokers covered by Medicaid to make higher co-payments has not been numbered or released. When it is, you can find it here: 1.usa.gov/wcEWge.